“That doctors should leave messages on answerphones for patients to make contact with them…”
Dated 7 Mar 2018, from the coroner for Inner West London. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Report put online after its 56 daysOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
judiciary.uk put this report online on 16 Jun 2018, after the 56 days for replies had ended (2 May 2018). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated7 Mar 2018
- Deadline2 May 2018
- Published on judiciary.uk16 Jun 2018
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| St George's University Hospitals NHS Foundation TrustNamed in the report as “St Georges Hospital” | Response publishedPublished on judiciary.uk in June 2018. |
| General Medical Council | Response publishedPublished on judiciary.uk in June 2018. |
| Department of Health and Social CareNamed in the report as “Department of Health” | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 16 Jun 2018, after the 56 days for replies had ended (2 May 2018). These dates can’t tell us whether a reply was due before it went online. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
1. That doctors should leave messages on answerphones for patients to make contact with them in urgent and emergency situations. 2. That doctors shauid attempt to contact patients via all contact phone nurnbers that they have access to for patients in urgent and emergency situations. 3. That in urgent and ernergency situations risk to life should be considered the priority. 4. That hospital guidelines and St George’s hospital guidelines in particular, in relation fo such matters, should be updated and amended to reflect the above where needed. 5. That hospitals and St George's Hospital in particular, should ensure that all relevant staff have their training updated in a prompt and auditable fashion to reflect the concerns raised above. 6. That the GMC considers its guidance for doctors and amend where necessary to ensure that itis clear that messages may be left for patients in urgent and emergency situations. 7. That the Department of Health also considers its guidance that it issues in relation to such matters, and amend where necessary to ensure that it is clear that messages may be jeft for patients in urgent and emergency situations. 8. That the GMC and Department of Health both take steps to ensure that the clarifications as outlined above are communicated to all doctors by the GMC and to all relevant staff employed by the NHS by the Department of Health.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2018-0073
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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